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Not Documented, Not Done: Medicare Myth or Rule?

December 29th, 2015 - Codapedia Staff
Categories:   Audits/Auditing   Claims   Documentation Guidelines  
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After years of unchallenged recitation, the coding community has virtually canonized the phrase “not documented—not done” into coding scripture. But there are good reasons to question whether the now-famous epigram reflects an actual rule or whether it has simply taken on a life of its own like other “urban myths.”
In a 2008 article that retains relevance to coders today, Michael D. Miscoe, CPC, CHCC, noted that thorough documentation has become the de facto requirement to support claims for reimbursement by government and private payors. But an objective investigation into Medicare rules and their supporting statutes won’t support the common belief that “not documented—not done” is a legitimate rule, he argued in the Journal of Medical Practice Management.

By a strict interpretation of Medicare rules, lacking documentation does not render a medical service noncompensable. The Social Security Act itself mandates no payment “unless there has been furnished such information as may be necessary in order to determine the amounts due” (42 U.S.C. §139(e). A “clean” claim with the proper ICD-9 and HCPCS codes and appropriate fees fulfills this requirement.

Recent case law further supports this conclusion: The federal court ruled against the U.S. in a False Claims Act (U.S. ex rel Sikkenga v. Regence Blue Cross Blue Shield of Utah) case and reasserted that the Medicare statute only imposes an information requirement and “not a particular content requirement.”

Not So Fast!

A wary practice manager may want to hide this information from certain providers within his or her organization. Many group practices include physicians who reluctantly scrawl the briefest of “notes” for office encounters—sometimes inadequate for recording and communicating what happened during the visit. They sometimes hide behind a cavalier attitude summed up with, “ . . . I know what I did!”

Just because a strict interpretation of the law may extract some of the teeth from “not documented—not done,” that doesn’t reduce the need for good, accurate, and thorough documentation. Quality patient care includes maintaining a record that allows anyone with a legitimate reason to pick up the chart to understand the patient’s history of diagnosis and treatment.

Average physicians see thousands of patients each year. Regardless of claims to the contrary, a documentation-averse provider seldom possesses memory skills capable of recalling unwritten details years later.

Although the OIG’s own audit manual names documentation as only one of four types of “evidence” to determine whether a particular service was performed and properly reimbursed, why put auditors, your practice, and yourself through substantial anguish to prove your case? Doesn’t it make much more sense to document well?


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